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Case Series/Study
Anal fistulas are highly prevalent and are a significant global burden associated with morbidity and mortality1. Patients experience pain, fever, malaise, drainage, and incontinence which contribute to a decreased quality of life. The reoccurrence rate and failure to preserve the sphincter remains high (30-50%), often resulting in multiple procedures, all of which contribute to decreased quality of life2. As such, new methodologies are needed for the treatment of anal fistulas. Fish skin graft (FSG) is a relevantly new biologic that is minimally processed and inherently low immunogenicity with preserved mechanical and biological components3. FSG allows rapid cellular ingrowth resulting in faster healing rates and less contracture when compared to mammalian tissues4,5.
Methods:
Two male patients (n=2) presented with anal fistulas and underwent fistulectomy. Patient one (38-year-old male) and Patient two (50-year-old male) presented with intersphincteric and complicated transphincteric fistulas, respectively, that were treated operatively. Both patients underwent excision and were treated with fragmented FSG packed into the sinus at the time of excision.
Results:
Patient one showed no signs of erythema, and drainage was minimal. The incision displayed advanced healing seven days postop. On day eighteen, continued healing was observed with no complications to report. By day thirty-nine, the incision was fully healed and remained complication-free. The patient was followed prospectively for an additional two months, and the surgical excision and repair were preserved.
On day fourteen, Patient two presented with remarkable incisional regeneration with little drainage or pain. By day forty-five, the patient was healed and presented with no complications.
Discussion:
Anal Fistulas have a high prevalence and incidence rate, with epidemiological studies estimating an overall prevalence in European countries at 18.37 (95% CI: 18.20-18.55%) per 100,000 individuals6. Surgeons have a plethora of treatment options that are guided by severity and etiology. The mainstay surgical treatment goals are to manage pain, secondary infection, and sepsis, promote sinus tract healing and preserve sphincter function and continence mechanism1. With postop reoccurrence rates high, there is a need for new treatment options. FSG in this small population appears to attenuate inflammation and secondary infection while rapidly regenerating the sinus tract. FSG has inherent Omega3 fatty acids, low immunogenicity, and is homologous to the human dermis in mechanical and biological content. FSG is an advanced biological scaffold that may reduce inflammation and drainage while rapidly regenerating the anoderm, reducing infection, and preserving sphincter function.
Trademarked Items: *KerecisTM, Kerecis, Isafjordur, Iceland
References: 1. Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol. 2015 Jan 7;21(1):12-20. doi: 10.3748/wjg.v21.i1.12. PMID: 25574077; PMCID: PMC4284327.
2. Dudukgian H, Abcarian H. Why do we have so much trouble treating anal fistula? World J Gastroenterol. 2011 Jul 28;17(28):3292-6. doi: 10.3748/wjg.v17.i28.3292. PMID: 21876616; PMCID: PMC3160532.
3. Baldursson BT, Kjartansson H, Konrádsdóttir F, Gudnason P, Sigurjonsson GF, Lund SH. Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: a noninferiority study. Int J Low Extrem Wounds. 2015 Mar;14(1):37-43. doi: 10.1177/1534734615573661. Epub 2015 Mar 9. PMID: 25759413.
4. Magnusson S, Baldursson BT, Kjartansson H, Rolfsson O, Sigurjonsson GF. Regenerative and Antibacterial Properties of Acellular Fish Skin Grafts and Human Amnion/Chorion Membrane: Implications for Tissue Preservation in Combat Casualty Care. Mil Med. 2017 Mar;182(S1):383-388. doi: 10.7205/MILMED-D-16-00142. PMID: 28291503.
5. Stone R 2nd, Saathoff EC, Larson DA, Wall JT, Wienandt NA, Magnusson S, Kjartansson H, Natesan S, Christy RJ. Accelerated Wound Closure of Deep Partial Thickness Burns with Acellular Fish Skin Graft. Int J Mol Sci. 2021 Feb 4;22(4):1590. doi: 10.3390/ijms22041590. PMID: 33557424; PMCID: PMC7915828.